HYPERPROLACTINEMIA
INTRODUCTION - REGULATION
Normal levels :
• Women - 5 to 25 ng/mL
• Men - 5 to 15 ng/mL
Levels fluctuate during the day
and peak during sleep.
• Prolactin stimulates milk production from the breast and
modulates maternal behavior
• Hyperprolactinemia occurs most frequently due to PRL-secreting
pituitary adenomas (prolactinomas) & idiopathic
hyperprolactinemia.
• Occurs more commonly in Women
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ENDOCRINE CAUSES OF
HYPERPROLACTINEMIA
Hypothyroidism
Elevated TRH
Stimulates PRL
• Acromegaly is also associated with hyperprolactinemia as a
result of the lactogenic properties of GH
• Physiological hyperprolactinemia occurs in pregnant and
breast-feeding women
• Traumatic childhood experiences, such a separation from
parents or living with an alcoholic father, have been reported
to produce a greater predisposition to hyperprolactinemia.
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CLINICAL PRESENTATION OF
HYPERPROLACTINAEMIA
IN WOMEN
IN MEN
frequently present with
amenorrhoea & more rarely
galactorrhoea in women
Frequently present with
impotence & infertility
MACROADENOMAS
ADENOMAS
Headache & visual field
disturbance due to focal
erosion of the floor of the
sella turcica or displacement
of the infundibulum and
pressure on the optic chiasm
Prolactin-secreting adenomas
are the most common type of
pituitary tumor that causes
hyperprolactinemia
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HYPERPROLACTINEMIA
SIGNS AND SYMPTOMS
 Sexual function
• ovarian dysfunction
• Infertility
• reduced libido
• atrophic changes in the urethra and vaginal mucosa
• dyspareunia
 Breasts
• Breast enlargement
• Galactorrhea
 Reduced Bone mineral density - loss of the protective effect
of estrogens on bone resorption
 Acne and mild hirsutism may also develop
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RELEVANCE OF PSYCHIATRY
IN HYPERPROLACTINAEMIA
Increased rates of
depression, anxiety and
hostility
ADR of the
antipsychotic drugs
• Women tend be more prone to the behavioral effects of prolactin
than men
• ‘Functional’ hyperprolactinaemia - raised prolactin in the absence
of a pituitary adenoma. Endocrine marker of primarily
psychological disturbance
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MEDICATIONS AND
HYPERPROLACTINEMIA
• Typical neuroleptic medications can raise PRL level as
much as 20-fold
• Haloperidol is especially associated. (strong D2 blockade)
• Atypical antipsychotics are less associated. Except in case
of Risperidone (70 to 100%)
• All SSRIs have been associated
• Occurs in a dose dependent fashion & PRL level reaching
plateau.
Other medications include1. Oral contraceptives
2. Estrogens
3. TCAs
4. Metoclopramide
5. Verapamil
6. Propranolol
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MANAGEMENT
Investigations
Thyroid function
test
Pregnancy test
Chemistry panel
Brain imaging
study
MRI with
gadolinium
CT with contrast
Drug of
Choice
Alternative
medications
Bromocriptine
Dopamine
agonist reduces the
synthesis and
secretion of PRL
ADR
Severe
nausea
Dizziness
Many patients
cannot tolerate
the side effects
of bromocriptine
Quinagolide
Pergolide
Cabergoline
How Long?
Medication
discontinuation
usually leads to
a relapse of
hyperprolactine
mia
Must continue
indefinitely
Refractory to
medication?
Radiotherapy
Surgical
removal through
transsphenoidal
surgery (not
performed now)
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THANK YOU
REFERENCES
Kaplan and Sadock’s Comprehensive Textbook of
Psychiatry
LISHMAN’S - Organic Psychiatry
The American Journal of Psychiatry - 16 Dec 2019
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